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SAN JOAQUIN Environmental Health Department SITE MITIGATION WELL & BORING PERMIT APPLICATION For Wells and Borings Used for Contaminant Investigations and Remediation NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 48 Hours Advance Notice Required For All Inspections Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards. Job Address Ste A4 -1-1- c. k L r-7101ei 1,00")40.d City/State/Zip , cA Phone id/A Cross Street / ,SA• Vrp 7 AP N 2./ - - Property Owner* gar / A- &Net Co LI. C. Address / C 2 PJ C t " A. I fk c City/State/Zip -rr A•C CA 9S 3- C-57 C-57 Contractor -rea og., 4 Xds.r 4.) CA): r License# 0" 5 S Phone /6 - e53 - Address 3C M .t; k City/State/Zip 146k C cerio-9- /cA f_5-441.2. Consultant/Sub-Contractor tA)4 II 04 "• r•e i* 1 °. A C504 4 0-"License# Phone a9/4 — 14/1V City/State/Zip W "4- .S'A er4: m- -4" cA 56 f Address 3 0 647 19 It' 1- CONSTRUCTION WORK TO BE PERFORMED: `Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits NUMBER INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS 0 HOLLOW STEM BORING DEPTH 5- 1 0 r -7- 0 BOLTED TRAFFIC BOX 0 STOVE PIPE 0 HAMMER/DRIVEN DIA. OF BOREHOLE i .. O.= 4 0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA -S- 0 MUD ROTARY CASING THICKNESS TYPE OF CASING: 14 STEEL 0 PVC I:I OTHER ( ' '0 1).. re (.1- Fos 1-, R an PUSH POINT (GP/ CPT) CONDUCTOR CASING 0 Yes No Boring Dia: Casing Dia: Casing Depth: HAND AUGER GROUT SEAL DEPTH TREMIE TYPE TO BE USED: 0 AUGERS El HOSE 0 PIPE GROUT SEAL PUMPED? 0 Yes Dif No (Note: Maximum Freefall Depth is 30 Ft) ,. ..") GROUT SPECIFICATIONS IV e A 3- Ce..."... 1— r iv e- r-; ( A.1 = - - 1 4A A...7 ' Ce Phone 20f-832 - 7 Dot, TYPE OF WELIJBORING MONITORING EXTRACTION (Vapor/Water) SOIL VAPOR PROBE SOIL BORING El INJECTION (Air Spam, Ozonel OTHER 0 OTHER: WELU SOIL BORING IDs SG 2 0 C2, y DESTRUCTION WORK TO BE PERFORMED: # WELLS TO BE DESTROYED WELL IDs GROUT SPECIFICATIONS TREMIE TYPE TO BE USED 0 AUGERS ['HOSE 0 PIPE DESTRUCTION METHOD: (CHECK ALL THAT APPLY) p OVER-BORE DIAMETER of inches to depth of feet 0 PRESSURE GROUT To depth of feet below surface 0 EXPLOSIVES From to feet below surface 0 MUSHROOM CAP 03 feet below surface or _feet below surface if >3 feet COMMENTS: Signed Print Name I hereby certify that I am authorized to complete this application and that the work will be done In accordance with San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. Title/Company Pr •!' e 11A- •4- /40 &. Date Date ;? / / Application Accepted By: Grout Inspection By/Dates:14A Destruction Inspection By/Dates: Date Issued: ki /5/E X 11 bade,eLQ c3/i-f/ I Sw„eitAspecA-r10,& DEPARTMENT USE ONLY --••••-•—•-- FA Name •••• • IAVI ,..., k.k.A,cS k `r1 Cliks c 3 FA Address FA# 03 lidoa" PR# S4'() C-LSri FA PE .-Sji CC) WP Reviewed By L X Work Plan Date ri r i ter 0 C-57 ‘Authorization for Other to Sign Permit 0 Worker's Comp 0 Worker's Comp Waiver 0 Encroachment Permit 0 Access Agreement 0 Lead Agency Approval aff/frR -3 t, ,z, d ir ,:i1". ei, i. COMMENTS/CONDITIONS: Sbi I cu.,44-1,4 514,911 be ft4.,aci 0 I" f 14,511f, 57,v211h_il c--1 Co fv,, si.....-t-‘,.,3 v-- e‘.44,1 ,......ito cs-_,,„41..), s-te_e ( ed.---- , WP TYPE PE SC FEE INFO AMT REMITTED CHECK# RECY'D BY DATE WELL PERMIT# INVOICE# Permit "zyi 0 c 3/ $152x 3$ LI Cl, 57S---31 L )4 s i t - id P eo3g(ii4,1 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com EHD 29-01 08-01-17 Site Mitigation Well Permit Application